<div class="container">
    <div class="row">
        <div class="col-xs-12">
            <div class="panel panel-default">
                <div class="panel-heading">
                    <span>留言反馈</span>
                </div>
                <div class="panel-body">
                    <form class="form-horizontal" role="form">
                        <div class="form-group">
                            <label class="col-sm-4 control-label">内容：</label>
                            <div class="col-sm-5">
                                <textarea class="form-control" rows="3"></textarea>
                            </div>
                        </div>
                        <div class="form-group">
                            <label class="col-sm-4 control-label">联系方式：</label>
                            <div class="col-sm-5">
                                <input type="tel" class="form-control" placeholder="0794-1234567">
                            </div>
                        </div>
                        <div class="form-group">
                            <label class="col-sm-4 control-label">姓名：</label>
                            <div class="col-sm-5">
                                <input type="text" class="form-control" placeholder="小明">
                            </div>
                        </div>
                        <div class="form-group">
                            <label class="col-sm-4 control-label">验证码：</label>
                            <div class="col-sm-2">
                                <input type="email" class="form-control">
                            </div>
                        </div>
                        <div class="form-group">
                            <div class="col-sm-offset-4 col-sm-10">
                                <button type="submit" class="btn btn-default">提交</button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
</div>